Issues in Chiropractic Pediatrics: Vaccination

Thanks to Dynamic Chiropractic for releasing this missing Kids Need Chiropractic, Too article exclusively to Chiro.Org
http://www.chiro.org/LINKS/ABSTRACTS/Issues_in_Chiropractic_Pediatrics.shtml
Despite the current opinion of most in the medical community regarding the success of vaccines in the reduction of risks in contracting diseases that cause morbidity and mortality, current vaccination policies are controversial and an issue within and outside our profession.^1,2 There are those in our profession that advocate and embrace the use of vaccines, while others question its universal and/or mandatory implementation. This article will examine some of the issues that question the conventional practice of vaccination based on the scientific literature. A more complete discussion on the issue may be referenced elsewhere.³ In a future article, I will examine the development of new vaccines designed to address concerns of vaccination, such as its safety and immunogenicity.

Vaccine Failures

In the scientific literature, evidence exists documenting vaccine failures. Vaccine failures can be classified based on two major causes. There are primary causes, which are due to lack of seroconversion (failure to develop immunity to the vaccine), and secondary causes, which are due to a loss of immunity after initial seroconversion (waning immunity). Since seroconversion is rarely checked or established after immunization, it is difficult to distinguish the two causes. Despite a high rate of vaccine coverage in the population, sustained outbreaks have been observed with measles, mumps, pertussis and haemophilus influenza^4-7 that bring about the question of the efficacy of vaccines.

Adverse Reactions and Vaccine?Induced Autoimmunity

Adverse reactions such as seizures; pyrexia; malaise/fatigue; nervous and musculoskeletal symptoms; rash; edema; thrombocytopenia; meningitis, etc., have been documented.⁸ Even more alarming, however, is the finding in the past few years of vaccine?induced autoimmune disorders. The pathogenesis of vaccine-induced autoimmunity may be similar to the mechanisms that have been proposed to explain the viral autoimmunity association.⁹

Some examples of autoimmune disorders attributed to vaccines documented in the scientific literature are the following:

* optic neuritis and myelitis with the tetanus toxoid¹⁰;

* immune thrombocytopenic purpura and diabetes mellitus with the measles, mumps and rubella (MMR) vaccine^11,12;

* Guillain?Barre syndrome, reactive arthritis and vasculitis with the influenza vaccine¹³; * multiple sclerosis with the swine flu vaccine¹⁴; and

* myasthenia gravis, Reiter's syndrome, systemic lupus erythematosus and CNS demyelination with the hepatitis B vaccine^15-18.

Herd Immunity

The concept of herd immunity asserts that nonvaccinated individuals are protected within the population by those that are vaccinated. Several arguments are given against this reasoning. For example, in the case of polio, there is an increased risk of contracting polio in the herd from those individuals that have been vaccinated, since this infection occurs mainly from direct contact or fecal contamination. In mathematical modeling, a vaccine efficacy of 95-97 percent is required to interrupt the transmission of any disease and to prevent outbreaks should the disease be introduced to the population. Modeling also assumes a contact rate of 14-18 persons, that is, an infected person would come into contact with an average of 14-18 susceptible people. In school settings, the contact rate may be much higher.

Airborne transmission, if it is a factor, may also increase the contact rate. An increased contact rate in the mathematical model would require higher vaccination levels than that which presently exist. As Fine and Zell¹⁹ note, herd immunity thresholds for the elimination of disease are based on the assumption that immune and susceptible individuals are randomly distributed, which they are not. Also, vaccine failures are not randomly distributed, and susceptible individuals may be clustered, isolating them from indirect protection by immune members of the population.

Antigenic Variability

Potentials factor in the resurgence of certain diseases in the United States and globally may be due to antigenic changes in wild?type microbes. For example, several strains of wild-type measles viruses have been shown to have genetic and antigenic variability.²⁰ According to Bellini et al.²¹, measles virus strains isolated in the United States contain the greatest number of overall genetic diversity to date. The accelerated rates for the more recent measles isolates are within an order of magnitude of the rates calculated for the influenza type A virus, a virus known to evolve in response to immunologic pressure.²² Rota et al.,²³ point to the possibility that vaccine pressure may have driven virus evolution a step forward and at a faster rate. Viruses are quite adept at evading or subverting stress thrown at them.²⁴ With respect to long-term effects, it is suggested that future variants may accumulate enough mutations that vaccine-induced immunity may no longer prevent so?called vaccine?preventable diseases.

With measles, sera from recently infected individuals neutralize the current wild-type viruses 4?8 times better than they neutralized the vaccine strains. This suggests possible differences between existing wild-type strains of the measles virus and vaccine strains. Antigenic drift in the polio virus has also been observed to produce a different strain not fully covered by the vaccine, as was demonstrated in Finland with an outbreak in 1984?1985.^25-27

Role of the Chiropractor

The crux of the question for our profession is fundamentally whether chiropractors should advocate to enhance the host response to illness through a holistic approach (e.g., chiropractic adjustments, nutrition, hygiene, etc.), or are these approaches to health care relegated to a secondary or a nonexistent role. On the other hand, should a chiropractor tell the parents of an inner city child living in poverty with poor hygiene and poor nutrition that they should not be immunized? I certainly do not advocate such a position in so much as the types of factors that could influence the child's health are not being addressed. Conversely, to advocate mass vaccination of the population without addressing the socioeconomic, hygienic and nutritional factors in an individual's health care program is an equally irresponsible position. There is ample evidence that vaccination needs to be directed to low income, minority preschool children.^28,29

Just what would happen if the population stopped vaccinating? Well, an interesting study was performed in which they did just that. In the republic of Czechoslovakia, mass BCG vaccination of newborns and repeated vaccinations of infants and adolescents have been performed since 1953. In 1986, the compulsory mass BCG vaccination program was discontinued in a selected area (two regions with about two million inhabitants and approximately 30,00 babies born every year). Only those newborns whose parents requested the BCG vaccination and those who came into contact with tuberculosis patients were vaccinated.

Over approximately six years, 82.8% of the total number of newborn infants (165,854) were not vaccinated. The control group for the study was formed from vaccinated children born in the remaining region in the country. In determining the risk of tuberculosis infection in the study population, Trnka et al.,³⁰ found the average risk of infection in children aged 0?6 years to be low (0.046%), and the annual risk of tuberculous disease to be 7/100,000. The majority of patients were symptom free with minimal disease, and the authors recommend the use of selective vaccination of high?risk individuals. A benefit analysis found that the advantages and disadvantages of BCG vaccination were in balance. In addition, the number of nonvaccinated children developing tuberculosis were so small that mass application of BCG was concluded to be redundant.³¹

In assessing the transmission of tuberculosis infection in the nonvaccinated population, the risk of infection was so low that infections rarely occurred below the age of one year and highest in the 2?3 year old group. In identifying the possible sources of infection (i.e., public places), the authors of the study noted the necessity of maintaining a high standard of hygiene.³²

In closing, I have raised only some of the issues regarding vaccination. To question conventional practice is constructive to our understanding and development of protocols in the prevention and treatment of disease. We should not be so myopic in our pursuit of efficacy, but must also consider the long?term consequences of a vaccination program. The use of antibiotics is a perfect example of this need for consideration.³³

Parents may choose to vaccinate their child according to the universal immunization program as established; they may choose to vaccinate on a disease by disease basis; or they may choose to reject the vaccination program altogether. Parents are taking an active role in the decision process whether to vaccinate or not vaccinate their child. A study by Fitzgerald and Glotzer³⁴ was undertaken to assess the informational needs of parents regarding childhood immunizations. They found that parents were very interested in information regarding the common side effects, the rare, serious side effects and the safety/risks of vaccines, as well as the contraindications of its use. It is important for doctors to provide as much accurate information as possible so that the parent(s) can make an informed choice regarding the health management and well being of their child. For the doctor, it is of paramount importance that the patient's right to self?determination is always being preserved.³⁵

References

1. Colley F, Haas M. Attitudes on immunization: a survey of American chiropractors. J Manipulative Physiol Ther 1994;17:584?590. 2. Cashley MAP. Letter to the editor: attitudes on immunization: a survey of American chiropractors. J Manipulative Physiol Ther 1994;18:420?421

3. Lonfranchi R, Alcantara J, Plaugher G. Vaccination issues. In: Anrig C, Plaugher G. (eds.) Chiropractic Pediatrics. Baltimore: Williams and Wilkins, 1998

4. Hirose M, Hidaka Y, Miyazaki C, Ueda K, Yoshikawa H. Five cases of measles secondary vaccine failure with confirmed seroconversion after live measles vaccination. Scan J Infect Dis 1997;29(2):187?190

5. Briss PA, Fehrs LJ, Parker RA, Wright PF, Sannella EC, Hutcheson RH, Schaffner W. Sustained transmission of mumps in a highly vaccinated population: assessment of primary vaccine failure and waning vaccine?induced immunity. J Infect Dis 1994;169(1):77?82

6. Kenyon TA, Izurieta H, Shulman ST, Rosenfeld E, Miller M, Daum R, Strebel PM. Large outbreak of pertussis among young children in Chicago, 1993: investigation of potential contributing factors and estimation of vaccine effectiveness. Pediatr Infect Dis J 1996;15(8):655?661

7. Booy R, Heath PT, Slack MP, Begg N, Moxon ER. Vaccine failure after primary immunization with haemophilus influenza type B conjugate vaccine without booster. Lancet 1997;349(9060):1197?1202

8. Davis RL, Marcuse E, Black S, Shinefield H, Givens B, Schwalbe J, Ray P, Thompson RS, Chen R. MMR2 immunization at 4 to 5 years and 10 to 12 years of age: a comparison of adverse clinical events after immunization in the Vaccine Safety Datalink Project. The Vaccine Safety Datalink Team. Pediatrics 1997; 100(5):767?771

9. Seery JP. The link between viral infection and autoimmunity. Rev Infect Dis 1990;12:1202?1203

10. Topaloglu H, Berker M, Kansu T, Saatci U, Renda Y. Optic neuritis and myelitis after booster tetanus toxoid vaccination. Lancet 1992;339:178?179

11. Niemimem MT, Peltola H, Syrjala MT, Majipernaa A, Kekomaki R. Acute thrombocytopenic purpura following measles, mumps and rubella vaccination. A report on 23 patients. Acta Pediatr 1993;82:267?270

12. Peltola H, Heinonen OP, Valle M, Paunio M, Virtanen M, Karanko V, Canteli K. The elimination of indigenous measles, mumps and rubella from Finland by a 12 year, two?dose vaccination program. New Eng J Med 1994;331:1397?1402

13. Blumberg S, Bienfang D, Kantrowitz FG. A possible association between influenza vaccination and small vessel vasculitis. Arch Intern Med 1980;80:847?848. 14. Kurland LT, Molgaard CA, Kurland EM, Wiederholt WC, Kirkpatrick JW. JAMA 1984;251:2672?2675

15. Biron P, Montpetit P, Infante?Rivard C, Lery L. Myasthenia gravis after general anesthesia and hepatitis B. Vaccine 1988;148:2685

16. Hassan W, Oldham R. Reiter's syndrome and reactive arthritis in health care workers after vaccination. BMJ 1994;309:94

17. Tudela P, Marti S, Bonal J. Systemic lupus erythematosus and vaccination against hepatitis B. Nephron 1992;62:236?237

18. Herroelen L, De Keyser J, Ebinger G. Central nervous system demyelination after immunization and recombinant hepatitis B vaccine. Lancet 1991;338:1174?1175

19. Fine PEM, Zell ER. Outbreaks in highly vaccinated populations: implications for further studies of vaccine performance. Am J Epid 1994;139:77?90

20. Tamin A, Rota PA, Wang Z, Heath JL, Anderson LJ, Bellini WJ. Antigenic analysis of current wild-type and vaccine strains of measles virus. J Infec Dis 1994;170:795?801

21. Bellini WJ, Rota JS, Rota PA. Virology of measles virus. J Infec Dis 1994;170:S15?31.

22. Almond JW. The attenuation of poliovirus neurovirulence. Ann Rev Micro 1991;8:737?771

23. Rota PA, Bloom AE, Vanchiere JA, Bellini WJ. Evolution of the nucleoprotein and the matrix genes of wild-type strains of measles virus isolated from recent epidemics. Virology 1994;198:724?730

24. McFadden G. Even viruses can learn to cope with stress. Science 1998;279:40?41

25. Hovi T, Huovilainen A, Kuronen T, et al. Outbreak of paralytic poliomyelitis in Finland: widespread circulation of antigenically altered poliovirus type 3 in a vaccinated population. Lancet 1986;1:14272

26. Huovilainen A,Hovi T, Kinnunen L, et al. Evolution of poliovirus during an outbreak: sequential type 3 poliovirus isolates from several persons shows shifts of neutralization determinants. J Gen Virol 1987;68:1373

27. Huovilainen A, Kinnunen L, Ferguson M, et al. Antigenic variation among 173 strains of type 3 poliovirus isolated in Finland during the 1984 to 1985 outbreak. J Gen Virol 1988;69:1941?1948

28. Centers for Disease Control. Measles -? Los Angeles county, California, 1988. MMWR 1989A;38:49?53

29. Wood D, Donald?Sherbourne C, Halfon N, Tucker MB, Ortiz V, Hamlin JS, Duan N, et al. Factors related to immunization status among inner city latino and african?american preschoolers. Ped 1995;96:295?301

30. Trnka L, Dankova L, Svandova E. Six years' experience with the discontinuation of BCG vaccination. 1. Risk of tuberculosis infection and disease. Tuber Lung Dis 1993;74(3):167?172.

31. Neu HC. The crisis in antibiotic resistance. Science 1992;257:1036?1038.

32. Trnka L, Dankova L, Svandova E. Six years' experience with the discontinuation of BCG vaccination. 2. Cost and benefit of mass BCG vaccination. Tuber Lung Dis 1993;74(4):288?292.

33. Fitzgerald TM, Glotzer DE. Vaccine information pamphlets: more information than parents want? Pediatrics 1995;95:331?334.

34. Trnka L, Dankova L, Svandova E. Six years' experience with the discontinuation of BCG vaccination 3. Transmission of tubercle bacilli in an unvaccinated population. Tuber Lung Dis 1994;75(4):266?270.

35. Teno JM, Sabatino C, Parisier L, Rouse F, Lynn J. The impact of the patient self?determination acts requirement that states describe law concerning patients rights. J Law Med Ethics 1993;21:102?108.

Joel Alcantara, BSc, DC Instructor, Palmer College of Chiropractic West San Jose, California